APRIL 2017 - Choosing Wisely Policies 2017-18 - Croydon GP
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Choosing Wisely Policies
2017-18
APRIL 2017
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
1Version Control:
Version Description of Change(s) Reason for Change Author Date
1.0 Incorporation of 22 Urgent need to Albert De February
policies authorised by review policies Souza & 2017
Croydon CCG Governing SWL
Body in January 2017,
rest of the policies as
agreed by SWL still
effective
Policy Update Tracker
Authorised Specialty Procedure Date Review Date
by Approved
Croydon MSK / T&O Carpal Tunnel January 17 January 18
Governing Syndrome
Body Epidural injections for January 17 January 18
lumbar back pain
Hip Replacement January 17 January 18
Knee Arthroscopy January 17 January 18
Knee Replacement January 17 January 18
Knee washout January 17 January 18
Therapeutic facet joint January 17 January 18
injections / medial
branch blocks
Dupyutren’s January 17 January 18
Contracture Surgery
ENT Grommets (Adults) January 17 January 18
Obstructive Sleep January 17 January 18
Apnoea
Pinnaplasty January 17 January 18
Nasal Surgery January 17 January 18
(Including Rhinoplasty,
Septoplasty &
SeptoRhinoplasty)
Tonsillectomy January 17 January 18
Ophthalmology Cataracts January 17 January 18
Vascular Varicose Veins January 17 January 18
Urology Circumcisions January 17 January 18
General Gallstones January 17 January 18
Surgery (Asymptomatic)
Gynaecology Hysterectomy for Heavy January 17 January 18
Menstrual Bleeding
Dermatology Minor Skin Lesions January 17 January 18
(Treatment of)
Skin resurfacing & other January 17 January 18
minor skin procedures
Podiatry Hallux Valgus Surgery January 17 January 18
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
2Contents
Contents ............................................................................................................................ 3
Introduction ....................................................................................................................... 7
Aesthetic Surgery ............................................................................................................. 9
General Principles............................................................................................................. 9
1. Breast Procedures ............................................................................................... 10
1.1 Reduction mammoplasty .................................................................................... 10
1.2 Gynaecomastia .................................................................................................... 11
1.3 Augmentation/ Mammoplasty ............................................................................. 11
1.4 Revision of breast augmentation ....................................................................... 12
1.5 Mastopexy ............................................................................................................ 12
1.6 Surgical correction of nipple inversion.............................................................. 12
2. Facial Procedures................................................................................................ 13
2.1 Rhytidectomy ....................................................................................................... 13
2.2 Rhinoplasty........................................................................................................... 13
2.3. Nasal Surgery (including Rhinoplasty, Septoplasty and Septorhinoplasty) .. 13
2.4 Pinnaplasty .......................................................................................................... 14
2.5 Repair of external ear lobes ................................................................................ 15
2.6 Hair replacement techniques to correct hair loss.............................................. 15
3. Body Contouring Procedures ............................................................................. 16
3.1 Apronectomy or Abdominoplasty ...................................................................... 16
3.2 Body contouring .................................................................................................. 16
3.3 Liposuction .......................................................................................................... 17
4. Skin and Subcutaneous Lesions ........................................................................ 17
4.1 Facial skin procedures ........................................................................................ 17
4.2 Tattoo removal ..................................................................................................... 17
4.3 Treatment of skin hyperpigmentation ................................................................ 17
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
34.4 Treatment of vascular lesions............................................................................. 17
5. Miscellaneous ...................................................................................................... 17
5.1 Injection of facial botulinum toxin for cosmetic indications ............................. 17
5.2 Hair depilation...................................................................................................... 18
5.3 Cosmetic genital surgery .................................................................................... 18
5.4 Keloidectomy ....................................................................................................... 18
6. Asymptomatic gallstones ................................................................................... 19
7. Circumcision ........................................................................................................ 20
8.0 Diagnostic .................................................................................................................. 21
8.1 Open magnetic resonance imaging (MRI) .......................................................... 21
8.2 Wireless capsule endoscopy and double balloon enteroscopy in obscure
gastrointestinal bleeding..................................................................................... 25
8.3 Wireless capsule endoscopy and double balloon enteroscopy in Crohn’s
disease ............................................................................................................... 256
9.0 ENT ....................................................................................................................... 27
9.1 (Adeno)Tonsillectomy ......................................................................................... 27
9.2 Grommets in older children (12 and above) and adults (ventilation tubes)
(Insertion of) ........................................................................................................ 28
9.3 Grommets in children under 12 (ventilation tubes) (Insertion of) ..................... 29
10. Eyes ...................................................................................................................... 31
10.1 Blepharoplasty (surgery on the upper & lower lid) ................................ 31
10.2 Brow lift .................................................................................................... 31
10.3 Cataract surgery....................................................................................... 32
11. Minor Skin Lesions (Treatment of) ..................................................................... 34
12. Scar Revision Surgery & Resurfacing................................................................ 36
13. Obstructive sleep apnoea in adults .................................................................... 37
14. Obstetrics, Gynaecology & Reproduction.......................................................... 41
14.1 Dilatation & curettage (D&C) ................................................................... 41
14.2 Female genital prolapse/stress incontinence (assessment of) ............. 42
14.3 Hysterectomy for heavy menstrual bleeding ......................................... 44
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
414.4 IVF/ICSI Treatment ................................................................................... 45
14.5 Uterine fibroids (minimally invasive surgery for) ................................... 45
15. Orthopaedic & Pain Management ....................................................................... 47
15.1 Acupuncture for Non- Specific Low Back Pain (LBP) ............................ 47
15.2 Autologous chondrocyte implantation ................................................... 49
15.3 Carpal tunnel syndrome (surgical treatment of) .................................... 50
15.4 Discectomy for lumbar disc prolapse (elective) ..................................... 52
15.5 Dupuytren’s contracture (fasciotomy/fasciectomy) ............................... 54
15.6 Epidural injections for lumbar back pain ................................................ 57
15.7 Ganglia (Excision of ganglia) .................................................................. 58
15.8 Hip replacement surgery (primary) ......................................................... 60
15.9 Knee arthroscopy ..................................................................................... 63
15.10 Knee replacement surgery (primary) ...................................................... 66
Appendix G: Knee Symptomatology, Radiology and Localisation and Oxford Knee
Score7............................................................................................................................... 68
15.11 Knee washout (in patients with knee osteoarthritis).............................. 69
15.12 Therapeutic facet joint injections/medial branch blocks ....................... 69
15.13 Thermal radiofrequency denervation of lumbar & cervical facet joints 73
15.14 Trigger Finger ........................................................................................... 75
16. Vascular ............................................................................................................... 76
16.1 Manual lymphatic drainage (MLD)........................................................... 76
16.2 Varicose veins .......................................................................................... 78
17. Podiatry ................................................................................................................ 79
17.1 Hallux Valgus Surgery ............................................................................................ 79
Appendix A: Croydon CCG Prior Approval Process and Individual Funding Process
.......................................................................................................................................... 80
Appendix B: Individual Funding Request Application Form ....................................... 83
Appendix C: Policy on alternative/homeopathic/ complementary therapies..................... 90
Appendix D – Eligibility for NHS funded wigs ............................................................... 91
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
51
Appendix E: Epworth Sleepiness Scale ...................................................................... 92
Appendix F: Classification of Pain Levels and Functional Limitations Table for
Primary Hip Replacement and Oxford Hip Score .......................................................... 93
Appendix G: Knee Symptomatology, Radiology and Localisation and Oxford Knee
7
Score .............................................................................................................................. 95
Appendix H – Lymphoedema Staging and Referral Criteria ............................................ 97
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
6Introduction
This document has 60 procedure thresholds which include 22 that have been revised from the 2014-
15 SWL ECI policy document. The remainder have not been amended and remain as per the 2014-
15 SWL ECI policy document.
All procedures are now subject to funding approval either via a Prior Approval process or subject to
an Individual Funding Request (IFR). The process that needs to be followed is detailed in Appendix A
(flowchart).
The policies within this document are a set of patient criteria to inform the commissioning of clinical
interventions in Croydon. For some procedures, such as dental implants and aesthetics, all cases
need to be reviewed through an individual application via Individual Funding Request (IFR) including
Exceptional Circumstances application
Aesthetic surgery for cosmetic purposes will not normally be funded by CCGs.
This document includes the criteria (with rationale/supporting evidence) that are required to be met in
order to receive approval for funding.
In order for funding to be agreed for an Choosing Wisely procedure outside of the criteria (or for
procedures where no specific criteria are given), the applicant must make a case for exceptional
circumstances (Individual Funding Request) by demonstrating that there is some unusual clinical
factor about the patient that suggests that they are:
Significantly different to the general population of patients with the condition in question.
Likely to gain significantly more benefit from the intervention than might be normally expected
for the average patient with the condition.
The fact that the treatment is likely to be efficacious for a patient is not, in itself, a basis for
exceptionality. Also the patient’s social circumstances including family or work-related factors are not
taken into consideration by the Individual Funding Request panel, which will consider the evidence and
decide upon funding. The IFR form is available as an appendix to this Document (Appendix B).
Applications for funding should be made on behalf of the patient by primary or secondary care
clinicians.
The Croydon CCG Choosing Wisely Policy is driven by the need to ensure that NHS funded treatments
are effective and evidence-based and that access to treatment throughout the Croydon area is equal
for patients with similar need. It also attempts to define more clearly and openly the limits of NHS
funding for procedures with social but not physical benefits cosmetic procedures. Although not the
main driving force, it is also linked to the need to ensure that the NHS provides value for money and
achieves financial balance.
The current procedures included in the Croydon CCG Choosing Wisely Policy document can broadly
be classified into four groups:
Procedures with limited evidence of effectiveness.
Procedures where initial conservative therapy is possible.
Effective procedures where a threshold for intervention may be appropriate.
Procedures where NHS provision may be inappropriate.
Criteria for funding of procedures is included in the Croydon CCG Choosing Wisely document are
developed on the basis of current evidence of best practice and in consultation with local clinical
teams.
A rolling programme is in place to ensure that criteria for procedures are up to date, are based on best
available evidence, and that new procedures are added to the document.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
7Homeopathic/Complementary therapies
These therapies are not funded by the NHS (Appendix C).
Procedures with limited evidence of benefit
This includes grommet insertion and tonsillectomy. For these procedures, the available evidence
suggests limited benefit and significant risks.
Procedures where initial conservative therapy is effective
This includes procedures such as hysterectomy for heavy menstrual bleeding where surgical
treatment may be considered but conservative therapy is effective and can avoid the risks associated
with surgery.
Procedures where a threshold for intervention may be appropriate
This includes cataract surgery. For these procedures, it is possible to select patient groups who are
unlikely to benefit from treatment.
Procedures where NHS provision may be inappropriate
This includes all cosmetic surgery and removal of some minor skin lesions. They are procedures for
which the primary purpose is to improve appearance and the evidence for other benefits, including
psychological, is limited.
It should be noted that procedures that have been the subject of NICE Technology Appraisals will be
amended without going through the usual consultation period. A list of those procedures amended will
be published as they occur.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
8Aesthetic Surgery
Definition
In this guidance aesthetic or cosmetic surgery is defined as surgery undertaken to improve one’s
appearance or reshape normal body parts to improve appearance. This differs from reconstructive
surgery which is undertaken to reshape abnormal structures of the body, from accidents, injuries,
infections, cancers or other diseases, as well as congenital deformities.
Aesthetic surgery for cosmetic purposes will not normally be funded by the CCG. All proposals need to
be approved as per local agreement (this may be Individual Funding Request (IFR) (See appendix B)
including Exceptional Circumstances application or other prior approval process e.g. referral review via
a Clinical Assessment Service (CAS)).
Note: Minor skin lesions are covered in a separate section of this document.
National Aesthetic Surgery Guidelines were published in Action on Plastic Surgery ‘Information for
Commissioners of Plastic Surgery Services. Referrals and Guidelines in Plastic Surgery’. The SWL
Public Health ECI network reviewed these guidelines, existing NHS policies and evidence of
effectiveness for individual procedures to produce a set of guidelines/criteria. Where the group found
no robust evidence, the guidelines/criteria in the table below represent a consensus view of who might
be considered appropriate for surgery and the actions which need to be taken before sending a
proposal to the IFR/exceptions/prior approvals panel. The table below describes the criteria/guidelines
for aesthetic procedures and should be considered against requests for procedures as indicated in
this policy document.
General Principles
1. Patients should be at least 18 years of age for most procedures (where this is the case the
procedure is annotated with “**”). It should be demonstrated that the conservative
treatments/options had been exhausted.
2. CCGs will not generally fund cosmetic procedures solely to improve appearance in the
absence of the following:
Disease, eg recurrent infection;
Congenital deformity (this does not include normal variation);
Limitation of function;
Impaired ability to perform activities of daily living.
3. Psychological distress alone will normally not be accepted as a reason to fund surgery.
4. In exceptional circumstances psychological distress alone may be considered as a reason for
cosmetic surgery if it may alleviate severe and enduring psychological dysfunction. In these
cases a NHS psychiatrist or psychologist must provide demonstrable evidence of treatment(s)
used to alleviate/improve the patient’s psychological wellbeing, including impact and duration
of treatment(s). Patients should be currently engaged or have undergone appropriate
psychological or psychiatric treatment. Patients should NOT be referred into mental health
services specifically to support an application for aesthetic surgery.
5. Clinicians are requested to refer to NICE CG31 Obsessive-compulsive disorder (OCD): Core
interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
1
disorder prior to referring on psychological grounds alone.
6. For patients with anxiety or depression, clinicians should consider a referral to the local
Improving Access to Psychological Therapies service before requesting cosmetic surgery.
References:
1. National Institute for Health & Clinical Excellence (NICE) CG31 Obsessive-Compulsive
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
9Disorder (OCD) and Body Dysmorphic Syndrome (BDS), Nov 2005
1. Breast Procedures
These criteria do not apply to cosmetic surgery following breast cancer treatment as this is
covered by cancer network commissioning policies and pathways.
1.1 Reduction mammoplasty
** (Female breast reduction)
Funding may be considered in the following circumstances:
The patient should be 18 or over at the time of application.
AND
Gross asymmetry of at least 2 cup sizes* difference between the breasts.
OR
BMI equal to or below 27;
AND
The patient has a bra cup size of F or more or requires at least 500g of tissue to be
removed from each breast**;
AND
If the patient has at least TWO of the following for at least one year (and documented
1
evidence of GP visits for these problems) :
Pain in the neck
Pain in the upper back
Pain in shoulders
Pain / discomfort / ulceration from bra straps cutting into shoulders;
AND
Pain symptoms persist as documented by the physician despite a 6-month trial of
therapeutic measures including all of the following:
Supportive devices (e.g., appropriate bra/support bra fitted by a trained bra
fitter, wide bra straps).
Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions.
Physical therapy / exercises / posturing
manoeuvres.
Chronic intertrigo, eczema or dermatitis alone will not be considered as grounds for
this procedure unless all of the above are met and the patient has failed to respond
to 6 months of conservative treatment.
*AA, A, B, C, D, DD, E, F, FF, G, GG, H, HH, J, JJ, K, L
** 500g estimates to a 4 cup size reduction in patients with chest sizes 30 to 34 or 2 cup size
reduction in patients with wider chests 34-40+.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
101. Aetna. Clinical Policy Bulletin: Breast Reduction Surgery and Gynaecomastia Surgery.
http://www.aetna.com/cpb/medical/data/1_99/0017.html
1.2 Gynaecomastia
** (Male breast reduction for gynaecomastia) (liposuction may form part of the treatment plan
for this condition)
It is important that male breast cancer is not mistaken for gynaecomastia and, if there is any
doubt, an urgent consultation with an appropriate specialist should be obtained.
The patient should meet the following criteria:
The patient should be 18 or over at the time of application;
AND
BMI of equal to or below 27;
AND
Have gynaecomastia of Grade III * i.e. Gross breast enlargement with skin redundancy
and ptosis so as to simulate a pendulous female breast;
AND
Have been screened for endocrinological or drug related causes.
Notes:
*Simon’s classification for gynaecomastia
Ila Minor but visible breast enlargement without skin redundancy. Ila Moderate breast enlargement
without skin redundancy
IIb Moderate breast enlargement with minor skin redundancy
III Gross breast enlargement with skin redundancy and ptosis so as to simulate a pendulous female
breast.
*Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast
Reconstr Surg. Jan 1973;51(1):48- 52
1.3 Augmentation/ Mammoplasty
** (Breast enlargement)
Criteria
The patient should be 18 or over at the time of application;
AND
Has significant asymmetry. (Significant asymmetry will be defined as a difference of at
least 2 full cup sizes*) to the extent that they cannot get a bra to fit;
OR
There is complete absence of breast tissue unilaterally or bilaterally.
*AA, A, B, C, D, DD, E, F, FF, G, GG, H, HH, J, JJ, K, L
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
111.4 Revision of breast augmentation
**
Criteria
The patient should be 18 or over at the time of application.
AND
Removal of implants will be considered, but not replacement, if at least one of the
following criteria are met:
Rupture of silicone-filled implant.
Implants complicated by recurrent infections.
Extrusion of implant through skin.
Implants with Baker Class IV contracture associated with severe pain.
Implants with severe contracture that interferes with mammography.
Replacement of implants will be considered, for clinical reasons, if the original implants
were funded by the NHS for non-cosmetic reasons.
1.5 Mastopexy
** (Breast lift)
The patient should be 18 or over at the time of application.
Mastopexy (Breast lift) will not be funded for purely cosmetic/aesthetic purposes such as
post-lactational ptosis.
NB for asymmetry see breast augmentation, for back pain as a result of breast size, see
breast reduction.
1.6 Surgical correction of nipple inversion
**
The patient should be 18 or over at the time of application.
See General Principles above.
Nipple inversion may occur as a result of an underlying breast malignancy and it is essential
that this be excluded.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
122. Facial Procedures
2.1 Rhytidectomy
** (Face lifts)
The patient should be 18 or over at the time of application.
See General Principles Above
2.2. Rhinoplasty
This policy does not apply to immediate post trauma nasal manipulation which normally occurs two to
three weeks after the trauma and does not require IFR approval from the Commissioner.
1. Rhinoplasty surgery is not routinely commissioned by the CCG
2. Septo-rhinoplasty is not routinely commissioned by the CCG
3. Septoplasty is only funded where there is evidence of a clinical blockage
4. Nasal surgery to correct the following is not routinely funded by the CCG:
to stop snoring
cosmetic appearance of the nose
for patients who are unhappy with the outcome of previous surgeries including immediate
post-trauma corrections (whether provided by the NHS or private providers)
5. Consideration may be given for the following:
post- traumatic nasal injury causing continuous and chronic bi-lateral nasal airway obstruction
associated with septal/bony deviation of the nose which as part of reconstructive head and
neck surgery (including traumatic deformity)
AND
there is significant functional impairment demonstrated d) applications put forward must
demonstrate some unusual or unique clinical factor about the patient that suggests they are
exceptional as defined below:
Significantly different to the general population of patients with the condition in question
Likely to gain significantly more benefit from the intervention than might be expected from the
average patient with the condition
Applications should be supported by photographs. The CCG will accept patients own
photographs
the CCG will NOT reimburse the costs of medical photography
2.3. Nasal Surgery (including Rhinoplasty, Septoplasty and
Septorhinoplasty)
Policy Statement Nasal surgery to correct deformity and the cosmetic appearance of the
nose,including Rhinoplasty and Septorhinoplasty is not routinely funded by the commissioner.
Rhinoplasty & Septoplasty requests via IFR, will only be considered where the patient has:
Post-traumatic nasal injury causing continuous and chronic bi-lateral nasal
airway obstruction associated with septal/bony deviation of the nose which is
causing significant functional impairment.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
13OR
Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial
deformity causing significant functional impairment*
*Significant functional impairment is defined as:
– Symptoms prevent the patient fulfilling routine work or educational responsibilities
– Symptoms prevent the patient carrying out routine domestic or carer activities
Septoplasty is allowed via criteria based access for the criteria stated below:
Asymptomatic septal deformity that prevents access to other intranasal
areas when such access is required to perform medical necessary surgical
procedures (e.g. ethmoidectomy)
Documented recurrent sinusitis, causing moderate to severe facial pain,
felt to be due to a deviated septum not relieved by appropriate medical
and antibiotic therapy after at least 6 months of medical therapy to include
budesonide, mometasone, fluticasone and nasal douching (see patient
information sheet).
Recurrent epistaxis (nosebleeds) related to a septal deformity which have
not responded to 3 attempts at cauterisation
Prior Approval should be sought by the secondary care clinician for Septoplasty for the following
indication.
Septal deviation causing continuous nasal airway obstruction resulting in nasal breathing difficulty
not responding to 6 or more months of documented appropriate medical therapy.
Croydon CCG will not normally approve funding for patients for snoring or are unhappy with the
outcome of previous surgeries including immediate post-trauma corrections (whether provided by the
NHS or private providers).
NB: This policy does not apply to immediate post trauma nasal manipulation which normally occurs
two to three weeks after the trauma and does not require prior approval from the Commissioner.
Smoking cessation is recommended for all patients considering the possibility of surgery.
2.4 Pinnaplasty
Cartilage moulding devices are advised in infants up to 6 months of age.
Surgery in the NHS should be available for children with significant deformity or asymmetry, where the
prominence measures >30mm (using the measuring guide below)
AND
Where there is evidence of psychological distress (presenting as documented episodes of bullying
and or school refusal) in children and adolescents with prominent ears in whom corrective surgery
should help to resolve these issues. Details should be provided in the referral letter.
Surgery below the age of 5 should only be offered if correction of prominence will help in retaining
hearing aids securely, in children for whom they are required.
It is recommended that surgery is only offered to children above 5 years of age and below 18
years of age, i.e. the upper age limit for referral is 17 years and 364 days. Children under the age
of 5 are less likely to tolerate the procedure well or be compliant with dressings care.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
14Psychological distress is unlikely to have developed prior to the age of 5 and surgery can
therefore be delayed until later.
NHS surgery for prominent ears should not be offered to adults over the age of 18 years.
Supporting Information for consideration of exceptionality Where surgery is requested outside of the
policy criteria above, the following supporting information is required:
The size of the prominence, using the measuring guide below.
Details of any psychological distress, this should include documented evidence of, for example,
bullying or school refusal to support the application.
Details of any functional problems.
Non-identifiable photographs, preferably medical illustrations if available to support the decision
making process. Photographs will be considered but will not form the sole basis of the decision. It is
not mandatory for photographs to be provided by a patient. If photographs are submitted then the
measuring device should not be touching the ear and thereby aiding the prominence.
Details of any clinical exceptional circumstances.
It is important that it is the child who desires surgical correction; referral should not be made for
children who appear indifferent or opposed to the idea of surgery. Parents requesting surgery for their
child in order to prevent psychological distress when their child starts school or at some time in the
future should be advised that referral should wait until their child specifically requests treatment.
Prominence of the ears is associated with bullying and significant psychological distress. In individuals
in whom preoperative distress is high, psychological therapy, whether or not subsequent surgery is
offered, should be provided.
Measuring guide
One of the most consistent methods for measuring the degree of prominence is the helical-mastoid
(H-M) distance. Typically, the HM distance is 18-20 mm. As the H-M distance increases, the ear is
perceived to be increasingly prominent.
Measure from the posterior aspect of the Helix.
Prominence = H-M distance > 20mm, but
Pinnaplasty will only be considered in patients who have a >30mm prominence, unless there are
other considerations e.g. in helping to retain hearing aids.
DO NOT REFER for prophylactic or cosmetic reasons for any case (Adult or Paediatric) as these
applications will automatically be refused.
2.5 Repair of external ear lobes
(Lobules)
Consideration will be given to completely split ear lobes as a result of direct trauma.
Note: If a previously repaired earlobe is pierced and the split recurs, no further treatment
will be offered.
If approved, Panels will agree funding for one episode of repair only
2.6 Hair replacement techniques to correct hair loss
(e.g. due alopecia or male pattern baldness)
This procedure is not routinely funded by the NHS. If clinical exceptional circumstances
exist, applications for funding can be made in the form of an individual application (such
as an Individual Funding Request (IFR).
In certain circumstances wigs may be considered clinically appropriate. Some patients,
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
15depending on their social circumstances may be eligible for a NHS funded wig (see
Appendix D).
Wigs will not be provided for normal hair loss due to age including male or female pattern
baldness.
3. Body Contouring Procedures
3.1 Apronectomy or Abdominoplasty
** (Tummy tuck)
The patient should be 18 or over at the time of application.
AND
At the time of the application the patient should have a BMI of between 18 and equal or
2
less than 27 kg/m and must have maintained a BMI in this range for at least 24 months.
OR
Further consideration may be given to people who have had very significant weight loss
post bariatric surgery who should have lost at least 50% of their original excess weight*
and maintained this weight for at least 6 months, and be at least 18 months post-surgery.
AND
Have severe functional problems which should include at least one of the following:
Severe difficulties with daily living i.e. ambulatory restrictions.
Documented record of recurrent intertrigo beneath the skin folds that recurs or
fails to respond despite appropriate medical therapy for at least 6 months
* Percentage of excess weight lost = initial weight – current weight x 100
2
initial weight – (25 x height )
(NB where weight is in kilos and height is in metres)
3.2 Body contouring
** (Other skin excision for contour e.g. buttock lift, thigh lift, arm lift (brachioplasty)
(For apronectomy/abdominoplasty in respect of body contouring see criteria for
apronectomy/adominoplasty above)
The patient should be 18 or over at the time of application;
AND
2
At the time of the application the patient must have a BMI of equal to or below 27 kg/m
and must have maintained a BMI in this range for at least 18 months;
AND
Have severe functional problems which may include:
Documented record of recurrent intertrigo beneath the skin folds that recurs or
fails to respond despite appropriate conservative treatment for at least 6 months.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
16 Severe difficulties with daily living i.e. ambulatory restrictions.
3.3 Liposuction
Liposuction will not be routinely funded to correct the distribution of fat. If clinical
exceptional circumstances exist, applications for funding can be made in the form of an
individual application (such as an Individual Funding Request (IFR).
4. Skin and Subcutaneous Lesions
4.1 Facial skin procedures
Skin resurfacing and other surgical interventions for scarring, including laser, dermabrasion
and chemical peels)
Skin resurfacing procedures for cosmetic purposes or purely to improve appearance will
not be routinely funded.
Individual requests will be considered on an exceptional basis where there is evidence
that the procedure will improve clinically significant signs and symptoms.
4.2 Tattoo removal
See General Principles above.
4.3 Treatment of skin hyperpigmentation
(including laser therapy, chemical peels etc.)
See General Principles above.
4.4 Treatment of vascular lesions
See General Principles above.
Individual requests will be considered on an exceptional basis which may include
evidence that facial lesions cause significant disfigurement or obstructive symptoms.
Small, benign, acquired, vascular lesions such as thread veins and spider naevi would
not normally be treated.
5. Miscellaneous
5.1 Injection of facial botulinum toxin for cosmetic indications
Botulinum toxin is not routinely funded for the treatment of facial ageing or excessive
wrinkles. If clinical exceptional circumstances exist, applications for funding can be made
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
17in the form of an individual application (such as an Individual Funding Request (IFR).
Botulinum toxin is available for the treatment of pathological conditions by appropriate
specialists in cases such as Frey’s syndrome-gustatory sweating after parotid surgery;
Botox A injection is recommended as a first line treatment for Frey’s syndrome and can
be used in conjunction with or instead of oral anticholinergic medication.
5.2 Hair depilation
(Hair removal by electrolysis and/ or laser)
Treatment of severe hirsutism on the facial, neck and/or chest area will be considered if
standard treatments have failed and exceptionality is demonstrated.
The methods of hair removal used should be diathermy electrolysis performed by a
registered electrologist or, if appropriate, laser in the following circumstances and after all
standard treatments have been tried:
Abnormally located hair-bearing skin following reconstructive surgery.
Treatment for pilonidal sinuses to reduce recurrence.
Funding will be agreed for a course of treatment after which a review of effectiveness will
be required prior to any further funding being agreed.
5.3 Cosmetic genital surgery
See General Principles above
5.4 Keloidectomy
If the keloid:
Results in significant functional impairment.
OR
Causes significant pain requiring chronic analgesic medication.
OR
Bleeding.
OR
Suspicion of malignancy.
OR
Obstruction of orifice or vision.
OR
Failure to respond to intralesional steroid injection.
Panels will take into consideration the number of previous surgeries.
If approved, Panels will agree funding for one repair only and for steroid and/or radiotherapy as
clinically indicated.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
186. Asymptomatic gallstones
Croydon CCG will not fund cholecystectomy for asymptomatic gallstones.
Asymptomatic gallstones are gallstones detected incidentally in patient who do not have any
abdominal symptoms or have symptoms that are not thought to be due to gallstones.
Rationale
NICE Guidelines, CG188, 2014
NICE Clinical Knowledge Summaries (CKS)
RCS Commissioning guide for gallstones, 2013
References:
1. Mata A; Bouza C; Salinas J; Salvatierra L D; Freire E. Asymptomatic cholelithiasis in kidney
transplant recipients: Systematic review of surgery appropriateness…..Value in Health, June
2012, vol./is. 15/4(A79), 1098-3015 (June 2012).
2. Sakorafas G H, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really
needed? A critical reappraisal 15 years after the introduction of laparoscopic
cholecystectomy. Dig Dis Sci. 2007 May;52(5):1313-25. Epub 2007 Mar 28.
3. Kao L S, Flowers C, Flum D R. J Gastrointest Surg. 2005 Sep-Oct;9(7):965-72. Prophylactic
cholecystectomy in transplant patients: a decision analysis.
4. Halldestam I, Enell E L, Kullman E, Borch K. Development of symptoms and complications in
individuals with asymptomatic gallstones. Br J Surg 2004;91:734-8.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
197. Circumcision
The CCG does not commission Circumcision surgery for personal, social, cultural or religious reasons
and patients or their parents seeking this procedure should not be referred for CCG funded treatment.
The CCG does not commission Circumcision surgery for the prevention of sexually transmitted
diseases or where a patient is suffering from pain on arousal or interference with sexual function.
Funding approval for male circumcision will only be provided by the CCG for patients with the
following indications:
1. Recurrent Paraphimosis – Circumcision will be funded for patients suffering from
documented, clinically significant recurrent paraphimosis
OR
2. Pathological Phimosis - a. Circumcision will be funded where there is evidence of
pathological white scarring of the foreskin secondary to Balanitis Xerotica
Obliterans [BXO] in a child 4yr age or older AND the patient is suffering from pain or
difficulty in passing urine AND conservative management has failed or is
inappropriate. b. Circumcision will be funded where a patient has an abnormal
urinary tract and circumcision is proposed as part of the management of this
underlying condition. Circumcision will not be funded where a patient has non-
retractile ballooning of the foreskin and/or spraying of urine or non-significant
balanitis (up to 3 episodes in one year).
OR
3. Balanitis or Balanoposthitis – Circumcision will be funded for patients suffering from
documented, clinically significant recurrent episodes (more than 3 in one year) of
Balanitis or Balanoposthitis which has not responded to appropriate conservative
management such as self-care, topical treatment or medication.
OR
4. Physiological Phimosis - a. Circumcision will be funded where a patient is –
i. suffering from recurrent urinary tract infection,
AND
ii. Over 10 years of age, AND iii. non-surgical methods have proved ineffective –
a minimum of 4 weeks is recommended.
Female Circumcision Female Circumcision often known as Female Genital Mutilation (FGM) is
prohibited by law (Serious Crime Act 2015) and will therefore not be funded by the CCG. Incidences
where parents seek advice on FGM must be reported to the local Children Safeguarding Team.
Rationale
1
https://www.rcseng.ac.uk/standards-and-research/nscc/commissioning-guides/topics/
1
https://www.bma.org.uk/advice/employment/ethics/children-and-young-people/male-circumcision
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
208.0 Diagnostic
8.1 Open magnetic resonance imaging (MRI)
Prior approval should be sought from the CCG.
CCGs will fund:
Low field MRI for interventional and intraoperative procedures only.
Fund Open MRI of greater than >0.5T as an alternative to conventional MRI in the following
circumstances:
1
Patients who suffer from claustrophobia where taking an oral prescription sedative to
support conventional MRI has been tried and was not effective.
OR
Patients who cannot fit safely or comfortably in a conventional MRI, due to obesity or to
some other confirmed clinical condition.
1. GPs should prescribe an oral sedative before referring for an Open MRI
2. Standard MRI has a 60 cm bore and can tolerate a maximum weight of 250 kg. Latest
Standard MRI machines have an 80cm bore and are able to scan obese patients. Please
check before referring for an Open MRI.
CCGs will not routinely fund:
Standing, Weight-Bearing, Positional, or Upright MRI except on an exceptional basis via the IFR route.
Introduction
MRI is a widely used diagnostic imaging technology and is particularly useful in detecting soft tissue
damage and disease. The patient undergoing imaging is placed in a gradient magnetic field delivering
radiofrequency pulses to the patient and processing the resulting electromagnetic signals emitted from
1
the region being examined. (CADTH) T h e standard (closed/high-field) method of MRI requires the
patient to be in a supine or recumbent position. The orientation of standard MRIs requires the patient
to be horizontal and stationary. (Washington State) Magnetic resonance (MR) imaging (MRI) is
particularly useful in detecting soft tissue damage or disease.
For most scanners, the patient examination table is positioned in a long, narrow tube. Some patients
may experience claustrophobic reactions which might be effectively controlled by sedation or
anaesthesia. Obese individuals may not fit into the tube.
Open MRIs in which patients lie, sit or stand between two plates overcome these difficulties. They are
also used for intraoperative imaging or image-guided interventions where easy access to the patient is
required.
The technology
The quality of MRI images is partly dependent on the field strength of the magnet which is measured in
Tesla (above 1 Tesla (T) is considered high). Closed MRIs have magnet field strengths of >1.5 tesla
whereas open MRIs have medium strengths magnets of 0.5-1.0T The lower field strength of open
MRIs results in poorer quality images in comparison to closed MRIs, with lower signal-to-noise ratios
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
21and more motion artefacts. The length of time required to obtain an image is also longer.
Generally low field strength is below 0.5T, mid-field strength is 0.5 T, up to 0.9 T or 1 T; and high-field
strength is at/and or above 1 T. High-field devices are usually closed-bore magnets due to the fact
that the stronger magnetic fields (1–3 T) require more robust shielding and gradient structure to
maintain field homogeneity. The open magnet’s field strength usually varies from 0.2–1.0 T.
Evidence
MRI studies reported in the literature are generally based on intermediate- or high-field MRI.
There is insufficient evidence in the published peer-reviewed literature to support the use of
low-field strength MRI for any diagnostic indication including but not limited to the following:
breast (Paakko, et al., 2005); cardiac (Klein, et al., 2007; Rupprecht, et al., 2002);
cerebral/stroke (Terada, et al., 2006; Mehdizade, et al., 2003); pulmonary (Abolmaali, et al.,
12004; Wagner, et al., 2001); renal (Stecco, et al., 2007; Kajander, et al., 2000); multiple
sclerosis (Ertl-Wagner, et al., 2001) and retrocochlear disorders (Dubrulle, et al., 2002).
An evidence review performed by the Canadian Agency for Drugs and Technologies in Health
(CADTH)1 found several non-randomised trials which compared high and low field MRIs.
In a prospective study comparing a 0.2 T open scanner and a 1.5 T highfield system were
used to examine 401 patients.2 There was no significant difference in the diagnostic accuracy
of the two types of scanners in examinations for patients with diseases of the kidney (n=78),
shoulder (n=122), or spine (n=105), using surgical or clinical follow-up as the reference
finding. In cerebral examinations (n=96), the high-field system had a statistically significant
advantage in accuracy (p=0.01). The authors suggest that limitations due to field strength are
relevant only in a small number of cases that warrant high-field examination.
In a study on MRI arthrography of the shoulder, a 0.2 T open MRI and a 1.5 T high-field
system were used to examine 38 patients. Correlation of surgical and MRI findings was
available for 27 patients (71%). The high-field MRI produced better image quality and fewer
motion artefacts than the open low- field MRI, but diagnostic accuracy in the cases with
surgical correlation was the same for both systems. The authors conclude that low-field MRI
compares favourably to high-field MRI in detecting major abnormalities of the shoulder, but
has disadvantages because of the duration of the examination, and the increased risk of
reduced image quality due to motion artifacts.
Michel et al. compared patients’ acceptance of MRI pelvimetry that was done using open 0.5 T
and closed 1.5 T systems. Of 30 women referred for pelvimetry, 60% preferred the open
system, 7% the closed system, and 33% had no preference. The image quality was adequate
in both systems.3 In a British study, 47 of 50 patients (94%) who had failed to complete a scan
in a conventional machine underwent successful MRI in a 0.5 T open system.
19
Enders et al (2011), a randomised controlled trial was carried out to investigate whether an
open panoramic MR scanner is superior to a short-bore MR scanner in reducing the
occurrence of claustrophobic events. A total of 174 were enrolled, 87 in the short-bore MR
group and 87 in the open MRI group. With 33 claustrophobic events in the short-bore group
(39% [95% confidence interval [CI] 28% to 50%) versus 23 in the open scanner group (26%
[95% CI 18% to 37%]; P = 0.08) the difference was not significant. Enders and colleagues
noted that the most problematic phases of the scan were patient positioning and entry into the
exam suite. The researchers also noted that the claustrophobic event rates remained
consistent—at more than 25 percent—regardless of patient characteristics and the
anatomical region being scanned. The conclusions were that even recent MR cannot prevent
claustrophobia suggesting that further developments to create a more patient-centered MR
scanner environment were needed. The claustrophobia screening tool, CLQ may be a useful
tool to detect patients at risk before claustrophobia occurs.
Interventional and Intraoperative
The use of MRI in guiding interventional and intraoperative procedures has become widely accepted
2
as standard of care in equipped facilities . There are limited comparative studies between this and
conventional approaches but there are several small, observational studies which indicate that MRI
2
can be used safely and effectively .
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
22Low–field MRI
There is insufficient evidence in the published peer-reviewed literature to support the use of low-field
strength MRI for any indication other than intervention guidance. There is a lack of data: clarifying the
impact of treatment decisions—based upon low- field interpretation—on patient outcomes; addressing
accuracy and impact of interpretation of low-field MR images outside the hospital setting (i.e., non-
radiologist interpretation); addressing any value of dynamic or positional low-field MRI compared to
conventional MRI, or impact to patient outcomes; and clarifying what role low-field imaging should hold
in the diagnostic algorithm of joint conditions. Due to insufficient evidence, it remains unknown if
substituting low-field strength MRI in place of conventional MRI causes a negative impact to diagnostic
accuracy, treatment planning and overall patient outcomes. The limited evidence fails to prove that the
use of low-field strength MRI in place of conventional MRI improves diagnostic accuracy, treatment
2
planning and overall patient outcomes .
Open and Semi-Open MRI
Open (i.e., extremity, upright, positional) MRI allows for imaging without the patient being placed within
an enclosed space. Open and semi-open MRI systems have a variety of configurations wherein the
patient is not completely surrounded by the magnet. Instead of a tunnel as with standard MRI, common
configurations are open along the sides and/or consist of a shorter tunnel such that only the portion of
the body being imaged is surrounded by the magnet. Some designs have flared ends or two large
discs separated by a pillar. Both are open on the sides, allowing for imaging in different patient
1
positions and for axial loading . Open-design has become the standard of care when conventional
design is contraindicated. Specifically, this includes patients with pulmonary and/or cerebrovascular
disease as well as patients who would require sedation for a conventional MRI such as severely
claustrophobic or paediatric patients.
Standing, Weight-Bearing, Positional, or Upright MRI
Upright, standing or positional MRI (uMRI) is a type of vertically open MRI that has been developed in
recent years. Such systems are open at the front and top, with the magnetic poles placed on either
side of the patient and allow for vertical (upright, weight bearing), horizontal (recumbent) positioning,
and dynamic kinetic flexion and extension maneuvers. Current uMRI scanners generally use medium
field magnets of 0.5T (e.g., GE Signa™ SP/i) or 0.6T (e.g., FONAR Upright™MRI).
Washington State published a Health Technology Assessment on Standing, Weight- Bearing,
1
Positional, or Upright MRI (2006). Some conclusions included :
There is limited scientific data available on the accuracy and diagnostic utility of standing,
upright, weight-bearing or positional MRI.
There is no evidence from well-designed clinical trials demonstrating the accuracy or
effectiveness of weight-bearing MRI for specific conditions or patient populations.
Due to the lack of evidence addressing diagnostic accuracy or diagnostic utility, standing,
weight-bearing, positional MRI is considered investigational and experimental.
References:
1. CADTH. Open Magnetic Resonance Scanner. Issue 92. November 2006
2. CIGNA. Magnetic Resonance Imaging- low field. CIGNA coverage policy 0444
3. Paakko E, Reinikainen H, Lindholm EL, Rissanen T. Low-field versus high-field MRI in
diagnosing breast disorders. Eur Radiol. 2005 Jul;15(7):1361-8. Epub 2005 Feb 12.
4. Klein HM, Meyners W, Neeb B, Labenz J, Truümmler KH. Cardiac magnetic resonance
imaging using an open 0.35 T system. J Comput Assist Tomogr. 2007 May-Jun;31(3):430-4.
5. Rupprecht T, Nitz W, Wagner M, Kreissler P, Rascher W, et al. Determination of the pressure
gradient in children with coarctation of the aorta by low-field magnetic resonance imaging.
Pediatr Cardiol. 2002 Mar-Apr;23(2):127-31. Epub 2002 Feb 19.
6. Terada H, Gomi T, Harada H, Chiba T, Nakamura T, Iwabuchi S, et al. Development of
diffusion-weighted image using a 0.3T open MRI. J Neuroradiol. 2006 Feb;33(1):57-61.
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
237. Mehdizade A, Somon T, Wetzel S, Kelekis A, Martin JB, Scheidegger JR, et al. Diffusion
weighted MR imaging on a low-field open magnet. Comparison with findings at 1.5T in 18
patients with cerebral ischemia. J Neuroradiol. 2003 Jan;30(1):25-30.
8. Abolmaali ND, Schmitt J, Krauss S, Bretz F, Deimling M, Jacobi V, et al. MRI of lung
parenchyma at 0.2 T: evaluation of imaging techniques, comparative study with chest
radiography and interobserver analysis. Eur Radiol. 2004 Apr;14(4):703-8. Epub 2004 Feb 10.
9. Wagner M, Bowing B, Kuth R, Deimling M, Rascher W, Rupprecht T. Low field thoracic MRI--
a fast and radiation free routine imaging modality in children. Magn Reson Imaging. 2001
Sep;19(7):975-83
10. Stecco A, Oronzo P, Armienti F, Borraccino C, Fossaceca R, Canalis L, et al. Contrast-bolus
MR angiography of the transplanted kidney with a low-field (0.5-T) scanner: diagnostic
accuracy, sensitivity and specificity of images and reconstructions in the evaluation of
vascular complications. Radiol Med (Torino). 2007 Oct;112(7):1026-35. Epub 2007 Oct 21.
11. Kajander S, Kallio T, Alanen A, Komu M, Forsstrom J. Imaging end-stage kidney disease in
adults. Low-field MRI with magnetization transfer vs. ultrasonography. Acta Radiol. 2000
Jul;41(4):357-60.
12. Ertl-Wagner BB, Reith W, Sartor K. Low field-low cost: can low-field magnetic resonance
systems replace high-field magnetic resonance systems in the diagnostic assessment of
multiple sclerosis patients? Eur Radiol. 2001;11(8):1490-4.
13. Dubrulle F, Delomez J, Kiaei A, Berger P, Vincent C, Vaneecloo FM, et al. Mass screening for
retrocochlear disorders: low-field-strength (0.2-T) versus high-field-strength (1.5-T) MRI.
AJNR Am J Neuroradiol. 2002 Jun-Jul;23(6):918-23.
14. Merl T, et al. Eur J Radiol 1999;30(1):43-53.
15. Loew R, et al. Eur Radiol 2000;10(6):989-96.
16. Michel SC, et al. Eur Radiol 2002;12(12):2898-905. 17. Spouse E, et al. Br J Radiol
2000;73(866):146-51.
17. Spouse E, et al. BR J Radiol 2000;73(866):146-51
18. Washington State Department of Labor and Industries, Office of the Medical Director.
Standing,weight-bearing, positional or upright MRI. Health Technology Assessment. Olympia
Washington State Department of Labor and Industries; May 31 2006
19. Enders J et al. Reduction in claustrophobia with short-term bore versus open Magnetic
Resonance Imaging – A Randomised Controlled Trial. PLoS One. 2011;6(8):e234
Date Approved: January 2017 Review Date: December 2018 Version Final 1.0
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